Missouri Part C State Performance Plan for 2005-2006 through 2010-2011 (Includes previously submitted 12/05 SPP with revisions noted) Submitted February 1, 2007 SPP – Part C Missouri Table of Contents Overview of the State Performance Plan Development:..............................................................................2 Indicator 1: Percent of infants and toddlers with IFSPs who receive the early intervention services on their IFSPs in a timely manner...............................................................................................................5 Indicator 2: Percent of infants and toddlers with IFSPs who primarily receive early intervention services in the home or programs for typically developing children.....................................................................8 Indicator 3: Percent of infants and toddlers with IFSPs who demonstrate improved:..............................10 A. Positive social-emotional skills (including social relationships);....................................................10 B. Acquisition and use of knowledge and skills (including early language/ communication); and.....10 C. Use of appropriate behaviors to meet their needs.........................................................................10 Indicator 4: Percent of families participating in Part C who report that early intervention services have helped the family:.................................................................................................................................12 A. Know their rights;...........................................................................................................................12 B. Effectively communicate their children's needs; and.....................................................................12 C. Help their children develop and learn............................................................................................12 Indicator 5: Percent of infants and toddlers birth to 1 with IFSPs compared to:......................................16 A. Other States with similar eligibility definitions; and........................................................................16 B. National data..................................................................................................................................16 Indicator 6: Percent of infants and toddlers birth to 3 with IFSPs compared to:.......................................19 A. Other States with similar eligibility definitions; and........................................................................19 B. National data..................................................................................................................................19 Indicator 7: Percent of eligible infants and toddlers with IFSPs for whom an evaluation and assessment and an initial IFSP meeting were conducted within Part C’s 45-day timeline......................................21 Indicator 8: Percent of all children exiting Part C who received timely transition planning to support the child’s transition to preschool and other appropriate community services by their third birthday including:...............................................................................................................................................25 A. IFSPs with transition steps and services.......................................................................................25 B. Notification to LEA, if child potentially eligible for Part B; and.......................................................25 C. Transition conference, if child potentially eligible for Part B..........................................................25 Indicator 9: General supervision system (including monitoring, complaints, hearings, etc.) identifies and corrects noncompliance as soon as possible but in no case later than one year from identification...28 Indicator 10: Percent of signed written complaints with reports issued that were resolved within 60-day timeline or a timeline extended for exceptional circumstances with respect to a particular complaint.34 Indicator 11: Percent of fully adjudicated due process hearing requests that were fully adjudicated within the applicable timeline..........................................................................................................................35 Indicator 12: Percent of hearing requests that went to resolution sessions that were resolved through resolution session settlement agreements (applicable if Part B due process procedures are adopted). ..............................................................................................................................................................36 Indicator 13: Percent of mediations held that resulted in mediation agreements....................................37 Indicator 14: State reported data (618 and State Performance Plan and Annual Performance Report) are timely and accurate........................................................................................................................38 Part C State Performance Plan: 2005-2010 Page 1 (OMB NO: 1820-0578 / Expiration Date: 01/31/2006) SPP – Part C Missouri Overview of the State Performance Plan Development: THIS OVERVIEW IS REPEATED WITH NO CHANGES FROM THE 12/1/05 SPP A preliminary draft of the Missouri State Performance Plan (SPP) was developed by the Division of Special Education, based in part on previous Annual Performance Reports to the Office of Special Education Programs (OSEP) which were developed in conjunction with the State Interagency Coordinating Council (SICC). The draft was presented to System Point of Entry (SPOE) directors in Jefferson City on September 8, 2005, and to the State Interagency Coordinating Council (SICC) on September 9, 2005. Based on feedback from these stakeholders, revisions were made and a revised draft of the SPP was posted on the Division’s website on October 15, 2005. SPOE/SICC members agreed to disseminate the SPP to larger audiences through Regional and Local Interagency Coordination Council (RICC/LICC) meetings, with comments returned to the Division by November 1. A revised draft was presented to the SICC November 18, 2005, and the final plan will be submitted to OSEP December 2, 2005. Public Dissemination and Reporting of Data: This State Performance Plan will be posted on the Department’s website under the First Steps Data, Reports and Publications link. DESE will report annually to the public on the state’s performance compared to the targets established in this SPP. In addition, DESE will report annually to the public on the performance of each System Point of Entry (SPOE). Specifics on the public reporting of data will be addressed under each SPP Indicator. Data for many of the SPP indicators are currently publicly available on the DESE website, and any additional indicators will be added to existing reports. Overview of Missouri’s Part C System: Missouri’s Part C system, First Steps, was redesigned with implementation beginning in April 2002 in five SPOE regions. Operations in the remaining 21 SPOEs were implemented in March 2003. The SPOEs were responsible for taking referrals, determining eligibility and developing the initial IFSP. After the initial IFSP meeting for a child, service coordination was handled by an ongoing service coordinator outside of the SPOE. Due to limitations of the original SPOE design, a new contract was implemented in July 2004 which reduced the original five SPOEs to three. This new contract has resulted in significant improvements in child find, timelines and service delivery. A similar contract has just been awarded in the remainder of the state. The new awards were made by the Missouri Office of Administration in late November 2005 and will be operational by February 2006. The 21 SPOEs will be reduced to seven, resulting in ten SPOE regions covering the state. Under the July 2004 SPOE contract that is in place in three regions of the state (serving approximately half of the state’s child count), and soon to be in place in the remainder of the state, SPOE administrators have the following responsibilities: • Employ and conduct personnel evaluations on service coordinators • Assure implementation of any corrective action resulting from a complaint decision or monitoring review • Assist the state agency with investigation of provider complaints • Collaborate with Division of Mental Health (DMH) Regional Centers to implement the DESE/DMH Interagency Agreement • Develop, implement, and maintain a system of provider recruitment • Organize, develop, and appoint a Regional Interagency Coordinating Council (RICC) • Develop, implement, maintain, and evaluate child find activities • Monitor the completion of service provider training. Ongoing service coordination (after the development of the initial IFSP) is provided by the Division of Mental Health (DMH), and SPOEs in regions under the new contract. The February 2006 contract will eliminate independent service coordinators leaving DMH and SPOE service coordinators to coordinate services for children and families in First Steps statewide. Part C State Performance Plan: 2005-2010 Page 2 (OMB NO: 1820-0578 / Expiration Date: 01/31/2006) SPP – Part C Missouri Services are provided by personnel meeting state qualifications who contract with DESE. Providers enroll with the Central Finance Office (CFO) and are selected from a matrix which provides basic information regarding availability, coverage area, and trainings completed, among other items. The Central Finance Office (CFO) is under contract with DESE to handle provider billing/claiming and reimbursement for services. The CFO also developed the child data systems, including the old SPOE software and new web-based system. The July 2004 and the February 2006 SPOE contracts require that the SPOEs organize a Regional Interagency Coordinating Council. Roles of the RICC include assisting the SPOE with public awareness, child find, and establishing a target child count. Development of General Supervision System: Since July 1, 2005, DESE has implemented a revised General Supervision system. This system includes standards and procedures regarding monitoring, public awareness, professional development, complaints processing, data collection, financial management, and interagency agreements. The general supervision system includes a series of scheduled data reviews designed to monitor SPOE compliance with Part C regulations as well as the public reporting of data at the SPOE and county levels. The current data reporting covers many of the State Performance Plan indicators, and any not already covered will be added to the reports. The reports are posted each month on DESE’s First Steps website. For a more detailed description of the general supervision system, see Indicator 9. First Steps Regional Consultants: Four regional First Steps consultants are available through a contract with the Child Care Resource and Referral Network, and work with SPOEs, service coordinators, service providers and RICCs. These consultants assist these groups in problem-solving and technical assistance around compliance and recommended practice. The First Steps Consultants also assist DESE by providing the first line of assistance to the field, supporting the Lead Agency in compliance monitoring and child complaint investigation, training providers and referral sources, conducting provider recruitment and improving implementation of Part C by decreasing non-compliance prior to monitoring reviews and increasing use of effective practices. Development of IFSP Quality Indicators Rating Scale (QIRS): Missouri has developed, in collaboration with stakeholders, the National Early Childhood Technical Assistance Center (NECTAC) staff, and national experts, an IFSP Quality Indicators Rating Scale (QIRS). The QIRS was designed to be used by the Part C program in Missouri for accountability and performance monitoring purposes. The QIRS addresses each area of the IFSP document in a Likert scale fashion, with "1" representing Unacceptable, "3" representing Acceptable, and "5" representing Recommended Practice. Each Likert scale item has a descriptor for determining into which category the IFSP fell for each area evaluated. The quality review will identify areas of strengths and concerns in IFSPs reviewed and aggregate data for the overall quality of IFSPs developed in each System Point of Entry region. Under the July 2004 and February 2006 SPOE contracts, the state will award incentive dollars to a SPOE region that demonstrates “high quality” IFSPs as determined by the ratings on the scale and meets or exceeds the performance standards identified in the contract. The Missouri Part C program is now incorporating the use of the Missouri First Steps IFSP Quality Indicators Rating Scale into the statewide monitoring and accountability system. The Quality Indicators can be found online at http://www.dese.mo.gov/divspeced/FirstSteps/pdfs/MOIFSPRateScale.pdf. Development of the Web-based Child Data Management Module: Missouri’s new web-based child data and IFSP system was released in June 2005 and implemented statewide September 1, 2005. The system contains all elements of referral, evaluation, eligibility determination, and IFSP development and implementation. The system is compliance-driven and will ensure compliance with regulations as well as best practices to the extent possible. New referrals to the Part C system are being entered into the web system, and many children with current IFSPs are being transferred to the system. Children who are expected to exit the First Steps program by September 2006 will not be transferred to the web system; therefore, not every child with an IFSP will be transferred. In the interim, all children will be accounted for through either the old software or the new web-based Part C State Performance Plan: 2005-2010 Page 3 (OMB NO: 1820-0578 / Expiration Date: 01/31/2006) SPP – Part C Missouri system. More complete data regarding demographics, health information, outcomes, domains, and IFSP specifics will be available online for children in the web system, and will become an integral part of Missouri’s general supervision system. Update for SPP submitted February 1, 2007 For each indicator in this SPP, it is noted whether the information is repeated with no changes from the SPP submitted in December 2005, or if changes were made to targets or improvement activities. The Annual Performance Report provides updates to the information in this SPP. Part C State Performance Plan: 2005-2010 Page 4 (OMB NO: 1820-0578 / Expiration Date: 01/31/2006) SPP – Part C Missouri Monitoring Priority: Early Intervention Services In Natural Environments Indicator 1: THIS INDICATOR IS REPEATED WITH NO CHANGES FROM THE 12/1/05 SPP WITH THE EXCEPTION OF AN ADDITIONAL IMPROVEMENT ACTIVITY Percent of infants and toddlers with IFSPs who receive the early intervention services on their IFSPs in a timely manner. (20 USC 1416(a)(3)(A) and 1442) Measurement: Percent = Number of infants and toddlers with IFSPs who receive the early intervention services on their IFSPs in a timely manner divided by the total number of infants and toddlers with IFSPs times 100. Account for untimely receipt of services. Overview of Issue/Description of System or Process: The provision of services for Missouri’s Part C program is comprised of the following: • Intake Service Coordination is provided by System Points of Entry (SPOEs) through contracts with the Lead Agency. Intake service coordinators accept referrals and coordinate the evaluation process to determine eligibility for the Part C system and develop the initial Individualized Family Service Plan (IFSP). • The Department of Mental Health (DMH), through an interagency agreement, funds ongoing service coordination for an agreed upon number/percent of infants and toddlers (approximately 40% of eligible children). Service coordination for all other eligible infants and toddlers will be provided statewide via service coordinators employed by SPOEs after January 2006. Independent service coordination will no longer be an option when the February 2006 contract is implemented. This revision will provide extensive oversight of service coordination activities. • Personnel meeting state qualifications who are under contract with DESE provide all other early intervention services required by Part C. These providers bill the Central Finance Office (CFO). The CFO, when applicable, bills Department of Social Services (Medicaid) who reimburses the CFO per the interagency agreement between the Division of Medical Services and DESE. • Payments to providers in Missouri’s Part C system are based on the state’s Medicaid reimbursement rate. This rate includes a natural environments incentive for services provided in those settings. The February 2006 contract arrangement with SPOEs will allow the SPOE to reimburse providers for mileage when serving children in rural or remote areas that do not have local providers. The model for service providers is an independent system where providers contract with DESE and enroll with the CFO. Providers are then chosen by the family from a service matrix. The February 2006 SPOE contracts require the SPOEs to provide services through the independent provider model and/or employment of or contracts with providers. A transportation incentive is also included in the new contracts which will allow SPOEs to reimburse providers for some travel costs. These options should help to ensure provider availability across the state. IFSP services data are collected through the Central Finance Office (CFO) authorization and billing system. The new web-based Child Data Management system has a “Review of Delivered Services” report where service coordinators can monitor the provision of services in accordance with the IFSP. In addition, the web system enables “real-time” entry of service authorization which the service providers can then access almost immediately. This real-time system will help eliminate delays in service provision due to delays in entry and the subsequent receipt of service authorizations. Discussions with SPOE directors and the SICC regarding the definition of “timely services” resulted in this list of considerations: Part C State Performance Plan: 2005-2010 Page 5 (OMB NO: 1820-0578 / Expiration Date: 01/31/2006) SPP – Part C Missouri • Since Missouri has an independent provider system, provider scheduling and feasibility of fitting a new child/service into a provider’s schedule in a timely manner must be taken into account • Service Coordination as a service is not a billed service for DMH and SPOE service coordinators, therefore should be excluded if the definition of timely services is based on service authorization and billing data • All services for a child must be timely to count a child as receiving timely services • Need to take frequency of the services into account • Need to look at compensatory services as a result of delayed implementation • Need to address any inconsistencies in data entry of authorizations and No Provider Available services. Baseline Data for FFY 2004 (2004-2005): Based on the considerations and recommendations listed above, Missouri will define “Timely Service” as follows: Each service for a child must be initiated within 30 days of the service authorization start date. Every service for every child will be evaluated for timeliness, and in order to determine that a child received services in a timely manner, all services must have started within 30 days of the initiation date. If a child has a “No Provider Available” (NPA) authorization, the child can not be counted as having received timely services, since this indicates that the service could not begin because no provider was available to provide the service. This definition was established through stakeholder involvement and applied retrospectively to previously gathered data. Children Receiving Timely IFSP Services 2004-05 Children Receiving All IFSP Services within 30 Days 4,743 Total Children Receiving IFSP Services 6,805 % of Children Receiving All IFSP Services within 30 Days I 69.7% I Children Receiving All IFSP Services within 30 Days is determined by subtracting the authorization start date for a given service from the first date of service. If one or more service on the child's IFSP is greater than 30 days or the child received a 'No Provider Available' authorization within the span of dates (7/1/2004 to 6/30/2005), the child is not counted as receiving all IFSP Services within 30 days. Discussion of Baseline Data: Prior to requirements and development of this State Performance Plan, the timely provision of services was not measured in this fashion, and it is important to note that during 2004-05 it was not known that these data would be used to derive the timelines. There are likely some inconsistencies between SPOEs and service coordinators in the way that IFSP service start dates are entered into the system; some may be entered based on provider availability, some on IFSP meeting dates, some on the date service is expected to start, etc. There is also inconsistency in the use and entry of No Provider Available authorizations. In order to make these data more consistent, technical assistance will be provided to service coordinators and SPOEs. The determination of timely services was made by looking at all services authorized for a child. If any one service began more than 30 days past the authorized start date, the child was not counted as receiving timely services. This results in 2,062 or 30.3% of children counted as not receiving at least one service within 30 days. However, approximately 98% of children receive at least one service within the 30 day timeline which indicates that the vast majority of children receive some services within 30 days. In order to account for the 30.3% of children receiving IFSP services who did not receive all services in a timely manner, the Division examined the data. Of the 2,062 children who did not receive all services in a timely manner, 894 received all services within 45 days of authorization (meaning 80.7% of children received all IFSP services within 45 days); another 409 had received all services within 60 days (86.7%). Also, 156 of the 2,062 children received at least one ‘No Provider Available’ authorization meaning that a provider was not available to provide the service for some length of time. The length of time for which no providers were available could not be easily ascertained from the data; therefore some children may have been without a provider for a short amount of time, possibly even less than the 30 day window. Part C State Performance Plan: 2005-2010 Page 6 (OMB NO: 1820-0578 / Expiration Date: 01/31/2006) SPP – Part C Missouri SPOE Regions with the lowest percent of children receiving all IFSP services within 30 days included Camdenton/Rolla (44.9%), Union (53.2%), Springfield (53.4%), Montgomery City (56.7%), and Cuba (59.4%). SPOEs with the highest percent included Hannibal (76.9%), Jefferson City (75.6%), and St. Louis County (75.2%). Looking at specific service types in which delays were experienced, 30.6% of the 304 Audiology authorizations from 7/1/2004 to 6/30/2005 were delivered after 30 days, along with 24.6% of 858 Nutrition Services authorizations, 19.7% of 370 Nursing Services authorizations, 14.4% of 5,797 Physical Therapy authorizations, 13.3% of 5,892 Special Instruction authorizations, and 12.3% of 7,239 Occupational Therapy authorizations. The services least prone to delay included Special Instruction-ABA (5.5% of 1,139 authorizations delivered after at least 30 days), Speech Language Pathology (9.5% of 10,058 authorizations), and Bilingual Interpretation (9.5% of 231 authorizations). Public reporting of these data will entail reporting by SPOE region on the percent of children receiving all services within 30 days. FFY Measurable and Rigorous Targets 100% of infants and toddlers with IFSPs will receive the early intervention services on All Years their IFSPs in a timely manner Improvement Activities/Timelines/Resources: Improvement Activities Timelines Resources Ensure consistency of usage/entry of authorizations data Spring 2006 SPOEs, Consultants for valid data Conduct regular data reviews to evaluate service coordinator contacts with families in SPOEs/Regional Centers that have delayed Service provision. Determine if the reason for delay is a service coordination or provider issue. Specifically look at services with highest 2005-2011 Lead Agency (LA) Staff, percents of delays. Implement strategies/sanctions for Quarterly Consultants correction of delay based on the information found. If/when non-compliance is identified, deploy consultants to assist in developing and implementing corrective actions. Analyze impact of transportation reimbursement, employment of providers and RICC/SPOE provider 2006-2007 LA Staff, Consultants recruitment activities in order to track trends and target provider recruitment after new contract structure in place Develop and implement Transdisciplinary Service 2005-2011 LA Staff, Consultants Training for service coordinators and providers NEW – Review/revise training materials for providers to address their decisions related to initiation of services 2007-2011 LA Staff, Consultants after initial IFSP decisions to authorize specific services Part C State Performance Plan: 2005-2010 Page 7 (OMB NO: 1820-0578 / Expiration Date: 01/31/2006) SPP – Part C Missouri Part C State Performance Plan (SPP) for 2005-2010 Overview of the State Performance Plan Development: See Indicator 1 Monitoring Priority: Early Intervention Services In Natural Environments Indicator 2: THIS INDICATOR IS REPEATED WITH NO CHANGES FROM THE 12/1/05 SPP WITH THE EXCEPTION OF REVISED TARGETS Percent of infants and toddlers with IFSPs who primarily receive early intervention services in the home or programs for typically developing children. (20 U.S.C. 1416(a)(3)(A) and 1442) Measurement: Percent = Number of infants and toddlers with IFSPs who primarily receive early intervention services in the home or programs for typically developing children divided by the total number of infants and toddlers with IFSPs times 100. Overview of Issue/Description of System or Process: Data on service locations are collected through the child data system in two ways. Following completion of the IFSP, a primary setting for the IFSP is selected by the IFSP team during initial and annual reviews. Second, in order to authorize a service, each service must indicate the location as Home, Other Family Location, Community Setting or Special Purpose Center/Clinic. The web system requires a justification for any service authorized in a non-natural environment. Justification for services provided outside of the natural environment has been monitored in conjunction with SPOE visits, and is not an area where problems have been found, except for some isolated situations. The IFSP Quality Indicators Rating Scale includes a section evaluating justification of services outside the natural environment. Baseline Data for FFY 2004 (2004-2005): Primary Setting for children under 3 years of age with active IFSPs 12/1/2002 % 12/1/2003 % 12/1/2004 % Home 2276 77.4% 3042 88.9% 3126 90.7% Program Designed for Typically Developing Children 228 7.7% 229 6.7% 212 6.2% Total 85.1% 95.6% 96.9% Program Designed for Children with Developmental Delay or Disabilities 182 6.2% 124 3.6% 78 2.3% Service Provider Location 1 0.0% 10 0.3% 11 0.3% Hospital (Inpatient) 1 0.0% 6 0.2% 16 0.5% Other Setting 254 8.6% 12 0.4% 2 0.1% Discussion of Baseline Data: Missouri has a very high percentage of children served in natural environments according to the primary setting data. Similarly, service location data from October 2005 show that 74.6% of services are provided in the home, 15.9% in community settings and 2.0% in other family locations, totaling 92.5% of services provided in natural environments. Both the primary setting data and the service location data show high levels of services provided in natural Environments in the State. However, there are areas of the state that have a disproportionate number of services provided in special purpose centers. These areas are Part C State Performance Plan: 2005-2010 Page 8 (OMB NO: 1820-0578 / Expiration Date: 01/31/2006) SPP – Part C Missouri reviewed during the quarterly data review process and consultants have been directed to visit certain special purpose centers and to speak with service coordinators to gather more information regarding this issue. Data on the locations of services are publicly reported by SPOE region in the Key Indicators report which is posted on the web monthly. Primary setting data will be added to the public reporting of data. FFY Measurable and Rigorous Targets 95.0% of infants and toddlers with IFSPs will primarily receive early intervention 2005-2006 services in the home or programs for typically developing children 2006-2007 95.0% 2007-2008 95.0% 2008-2009 95.0% 2009-2010 95.0% 2010-2011 95.0% Improvement Activities/Timelines/Resources: See also Indicator 1 Improvement Activities Timelines Resources Implement regular data reviews and analyze service location data by region, demographic variables and Quarterly LA Staff & Consultants service types in order to target specific areas, groups, 2005-11 services or provider agencies During the data review process, assign consultants to investigate specific agencies where there is a high level Quarterly of services in a special purpose center and assist in Consultants 2005-11 development and implementation of improvement plans or corrective actions where necessary Part C State Performance Plan: 2005-2010 Page 9 (OMB NO: 1820-0578 / Expiration Date: 01/31/2006)